A Transatlantic Viewpoint on the Role of Pallidal Stimulation for Parkinson's Disease
Bibliographic record
Abstract
For many neurologists, crossing borders during training is part of the trajectory to becoming a movement disorders specialist and offers novel insights.In this viewpoint, we discuss how crossing the Atlantic Ocean, moving from Europe to North America, changed our approach to choosing a deep brain stimulation (DBS) target for the treatment of Parkinson's disease (PD).Although the debate on whether the subthalamic nucleus (STN) or the globus pallidus internus (GPi) is the preferred target for DBS is no longer a hot topic and is possibly considered a solved controversy, a new debate has recently emerged, after the publication of the European guidelines on advanced therapies for PD.[1][2][3] Moreover, with the recent implementation of magnetic resonance imaging-guided focused ultrasound (MRgFUS), 4 which can also be used to target the GPi, pallidotomy (performed using either radiofrequency or MRgFUS) may gain traction again.Therefore, we believe that sharing our view would be of interest to readers on both sides of the Atlantic.STN DBS just celebrated its 30th anniversary in Grenoble, France, where it was introduced in the early 1990s.5 Pallidotomies were the preferred stereotactic intervention for advanced PD before the introduction of DBS. 6 Despite the fact that shortly after the first report of STN DBS was published, 5 a series of patients treated with GPi DBS were reported, 7 STN quickly became the target of choice for PD, and GPi DBS was performed primarily for dystonia.8 This was true especially in Europe, where DBS entered the clinical space prior to U.S. Food and Drug Administration approval.In the past decade, several important clinical trials comparing STN to GPi were published.[9][10][11][12] Even though evidence has confirmed that both STN and GPi are effective targets in PD, 13 in Europe STN is still perceived as the DBS target of choice for PD, substantially outnumbering DBS procedures targeting the GPi.Despite our European training with STN being the preferred target, since arriving and practicing in Canada, each GPi case we have cared for has made us recognize why GPi as a target has been embraced in North America.Although the majority of patients respond well to STN DBS, 14 every DBS expert would concur that the potential outcome ranges between the miraculous effect often portrayed by the media, usually young tremordominant patients, and the disappointed patients in whom surgery and/or stimulation had a profound detrimental effect on speech, 15 cognition, 16 gait, and balance.17 Despite definite improvement in tremor and motor complications, 18 which is generally observed, the impact of these problems on function and quality of life makes these gains less significant.In contrast, the effect --------------------------
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.005 | 0.008 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.002 | 0.007 |
| Scholarly communication | 0.004 | 0.007 |
| Open science | 0.002 | 0.003 |
| Research integrity | 0.010 | 0.015 |
| Insufficient payload (model declined to judge) | 0.009 | 0.003 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".